Healthcare Provider Details

I. General information

NPI: 1053238840
Provider Name (Legal Business Name): JOHN ROSS CLARK RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45015 DEEPWOOD CT
SHELBY TOWNSHIP MI
48317
US

IV. Provider business mailing address

45015 DEEPWOOD CT
SHELBY TOWNSHIP MI
48317
US

V. Phone/Fax

Practice location:
  • Phone: 248-941-4338
  • Fax:
Mailing address:
  • Phone: 248-941-4338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number4704417487
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: